8/27/2019 Common Application Form

  (../ONLINE_CAF_Degree/userDashboardDeg.aspx)  Application Form

(../ONLINE_CAF_Degree/userDashboardDeg.aspx)


+3
Common Application Form

for Admission to Degree Colleges (2019-20)

Department of Higher Education, Government of Odisha *Mark indicates mandatory field

1. Name of the Council from which you have passed the +2 exam, Year of Exam & Roll Number (as in admit card)

Name of the Examination Council * Year of Passing * Exam Type * Roll Number *
27 - CHSE, ODISHA 2018 Annual Supple/Inst 372ma061

2. Applicant's Name * ASHUTOSH PATRA

3. Father's Name * KULAMANI PATRA

Upload photo *
4. Mother's Name * SABITA PATRA

Maximum Mark Total Mark Secured English MIL Chemistry Mathematics Biology
Mark secured in +2
(Science) Examination 600 416 55 84 65 61 0
Note : If the above mark showing in the computer screen is matching with your actual mark secured, then please click on “Yes” button. If not, click
on “No” button to enter your actual mark at 9(a) of this online form. Yes No

Blood Group Gender * Religion * Date of Birth *

5. Personal Details

--SELECT-- MALE HINDU 25 SEPTEMBER 2000

Nationality * Mother Tongue * Aadhaar No. Parent/Guardian Mobile No. *

INDIAN ODIA 817414881973 9938447562

6. Permanent Address

a. State * b. District * c. Block / ULB * d. House No., Street/Village, Post Office, Police Station Name *
1 - ODISHA BHADRAK BHANDARIPOKHARI AT-KHADISINGA,PO-RAHANIA,PS-BHANDARI POKHARI

e. PIN Code f. Telephone No. g. Mobile No. h. e-Mail

756120 - 7683811397 [email protected]

Area Code - Phone No

7. Reservation Details Application Fees = Rs 275

a. Schedule Tribe (ST) Schedule Caste (SC) Other Backward Class (OBC) Socially and Educationally Backward Class (SEBC) General
b. Persons with Disabilities (PWD)
c. Ex-Service Man (ESM) Children of Martyrs (CoM) Serving Defence Personnel (SDP) None

8. Weightage Details

a. NCC b. NSS Camp

NCC B NCC (CAMP/COURSE) University Level State Level National Level International Level

c. Rover & Ranger d. Sports & Games

https://online.samsodisha.gov.in/ONLINE_CAF_Degree/CAFDEG.aspx 1/2
8/27/2019 Common Application Form

Rajya Puraskar (RP) President Recognition (PR) State National International

Copyright © 2019 SAMS Application, All Rights Reserved

MIL Mark is not mandatory • Total Mark Secured, is the mark secured in all subjects of +2 Exam * 

9. Details of Mark Secured in +2 Council Examination *

Maximum
Total Mark Secured English MIL Chemistry Mathematics Biology
Arts Science Commerce Vocational Mark
a.
Diploma Upashastri
600 416 55 84 65 61 0

Have you passed +2 Council Exam Compartmentally / Instant

b. No Yes
?

10. Income Details of Parents

a. Father's Occupation * BUSINESS b. Mother's Occupation * HOME MAKER

c. Annual Income of the Parents (Together) in Rs. * 1,00,000 - 2,50,000

11. Bank Information

a. Account Number * 459115010961 b. IFSC Number * SBIN0010930 c. MICR Code

d. Bank Details STATE BANK OF INDIA - VIVEKANADA MARG BBSR *

12. Record of educational institution last attended

a. Name of the School * JUPITER SCIENCE COLLEGE b. Location of the School * GANGAPADA,BHUBANESWAR

c. District * KHURDA d. Year of Joining * 2016

e. Year of Leaving * 2018

You are required to select at least Five and at most TWENTY options.
Choose your 1st Option

a. College Type * Govt. / Aided / Private / Self Financing Sanskrit

b. District Name * -- SELECT --

c. College Name * -- SELECT -- d. Stream * -- SELECT --

e. Subject * -- SELECT --

f. Are you interested to reside in hostel ? * Yes No

Note: Do not click APPLY button, if you want to select more options.

2nd Option APPLY

https://online.samsodisha.gov.in/ONLINE_CAF_Degree/CAFDEG.aspx 2/2